LEUKEMIA

Reported by: Kristine Anne R. Ocio

 WHAT IS CANCER?
• CANCER is a complex of diseases which occurs when
normal cells mutate into abnormal cells that take
over normal tissue, eventually harming and
destroying the host

• A large group of diseases characterized by:

–Uncontrolled growth and spread of abnormal cells
–Proliferation (rapid reproduction by cell division)
–Metastasis (spread or transfer of cancer cells from
one organ or part to another not directly connected)

• BENIGN TUMORS
 CELL CYCLE
• G1-cell enlarges and
synthesizes proteins
• S phase-DNA
replication and
chromosomes are
duplicated
• G2-preparation for
mitosis
• M-mitosis
• G1-cycle begins again
• GO- resting phase
 Patterns of Cell Proliferation

Activated only in the presence of cellular

degeneration or death or there is a physiologic
need for more cells

• Hyperplasia
• Dysplasia
• Metaplasia
• Anaplasia
• Neoplasia
 HYPERPLASIA
• tissue growth based on an excessive
rate of cell division, leading to a
larger than usual number of cells

• Normal Hyperplasia
 DYSPLASIA
• Bizarre cell growth differing in size,shape and cell
arrangement

• Normal Hyperplasia Dysplasia

Normal Hyperplasia Dysplasia Severe Dysplasia Cancer
Carcinoma in situ Invasive
 Patterns of Cell Proliferation
Metaplasia

•conversion of one type of cell in a tissue to another

type not normal for that tissue

Anaplasia
• change in the DNA cell structure and orientation to
one another, characterized by loss of
differentiation and a return to a more primitive
form.

Neoplasia
•uncontrolled cell growth, either benign or malignant
 DEVELOPMENT OF CANCER
• INITIATION- is a mutation in the cells genetic
structure resulting from an inherited mutation,
an error that occurs in DNA replication, or
following exposure to a chemical, radiation or
viral agent.
• PROMOTION- once a cell has been mutated by an
initiator, it is susceptible to the effects of
promoters
• PROGRESSION-characterized by increased growth
rate as well as increased invasiveness and
metastasis.
 CLASSIFICATION OF CANCER
• Classification is made according to the site of origin,
histology (or cell analysis; called grading), and the
extent of the disease (called staging).

GRADING
• Grade I Cells slightly abnormal and well differentiated
• Grade II Cells more abnormal and moderately
differentiated
• Grade III Cells very abnormal and poorly differentiated
• Grade IV Cells immature and undifferentiated
CANCER STAGING- Staging is the classification of
the extent of the disease
CLINICAL STAGING
Stage 0 Cancer in situ (limited to surface cells)
Stage I Cancer limited to the tissue of origin,
evidence of tumor growth
Stage II Limited local spread of cancerous cells
Stage III Extensive local and regional spread
Stage IV Distant metastasis
 TNM CLASSIFICATION SYSTEM
Tumor (T)
• T0 No evidence of tumor
• Tis Carcinoma in situ (limited to surface cells)
• T1-4 Increasing tumor size and involvement
Node (N)
• N0 No lymph node involvement
• N1- 4Increasing degrees of lymph node involvement
• Nx Lymph node involvement cannot be assessed
Metastases (M)
• M0 No evidence of distant metastases
• M1-4 Evidence of distant metastases
 LEUKEMIA
“white blood”
uncontrolled
production of WBC
caused by cancerous
mutation of
myelogenous or
lymphogenous cells.
Blood’s cellular components originate primarily in the
marrow of the bones
 TYPES OF WBCs
Neutrophils-
-60-70% of total WBC
-active phagocytes
-1st to arrive at a site of injury
Eosinophils
-1-3% of circulating WBCs
-found in large numbers in mucosa and lungs
Basophils
- 1% of WBC count
-contain histamine, heparin and other inflammatory mediators
-increase during allergic rxn and inflammatory rxn
 TYPES OF WBCs
Monocytes
-largest
-3-8%
-phagocytic macrophages
-macrophages dispose of foreign and waste material,
esp in inflammation
Lymphocytes
-20-30%
-B cells-humoral immune response and antibody
formation
-T cells-cellular mediated immunity process
CLASSIFICATION

Onset: Acute/Chronic
Originating Cell:
Lymphocytic/Myelocytic
ALL-most common
in children
AML and CLL-
most common in
adults
 EPIDIMIOLOGY
• estimated 34, 810 new cases of leukemia occur annually; slightly
more than half are acute leukemia and less than half are chronic
leukemia

• In 2007 (the most recent year numbers are available),

36,273 people in the United States were diagnosed with leukemia,

(M- 20,629, F-15,644)
21,928 people in the United States died from leukemia, including
12,434 males and 9,494 females.

(†Source: at:http://www.cdc.gov/uscs.)
 Estimated new cases and deaths from leukemia in the
United States in 2010
(Source: National CancerInstitute-www.cancer.gov)
New Cases: 43,050
Deaths: 21,840

MORTALITY BY CAUSE, AGE GROUP AND SEX

Number and Rate/100,000 Population, Philippines, 2004
Male 1,234
Female 1,226
Both Sexes 2,460
Rate* 2.9

SELECTED CAUSES OF DEATH

By Region, Province and City
Number and Rate/100,000 Population, Philippines, 2004
Cagayan de Oro City
No. 18
Rate 3.5
• incidence is highest among whites and lowest among
Chinese, Japanese, and Koreans.

• The incidence in men is about 50% higher than in women for

all racial/ethnic groups except Vietnamese, among whom
the male rates are only slightly higher.

• Ethnic differences in the incidence rates are small in the

youngest adult age group (30-54 years), but become more
evident in each of the older age groups.

• Childhood leukemia rates are highest among Filipinos,

followed by white Hispanics, non-Hispanic whites and blacks.
(www.cdc.gov)
•  
PREDISPOSING FACTORS
 PRECIPITATING FACTORS
• Unknown
• HTLV-1( Viral cause
for Adult T-cell
Leukemia)
• Philadelphia
chromosome(CML)
PATHOPHYSIOLOGY
• LEGEND:

Disease Process
Symptoms

Treatment
(Drugs and Diagnostic
Procedures) Exams
 Predisposing Precipitating
factors factors

Chemotherapy
Malignant Radiation Therapy
transformation of a BMT,SCT
stem cell Bone marrow
aspiration, Biopsy

Destruction of Unregulated Proliferation Increase cellular

large number of of leukemic cells metabolism
WBC

Decrease Leukemic cells

Accumulation in leave bone
function of Antibiotics
the bone marrow marrow
WBC Corticoster
oid
Lumbar
puncture
Fever
Infection Leukemic cells
Night Sweats
Oral Ulcerations replace
Frequent Respi, hematopoietic Infiltration in the CNS,
Urinary, elements in testes, skin, GI tract,
Integumentary marrow lymph nodes, liver,
X-RAYS infections. spleen
 Compete with the
proliferation of
normal cells

RBC and platelet are

crowded out

CBC:
RBC<4X106/
Μl RBC count CBC: Platelet
Thrombocytopenia
Hgb may be <150,000/μL
less than
10g/100ml.
CBC:
RBC<4X106/
Μl
Bleeding Hgb may be
less than
Anemia
10g/100ml.
Pallor
Fatigue petechiae, ecchymosis,
Tachycardia conjunctival
hemorrhage, epistaxis, Blood
Lethargy
Dyspnea bleeding gums, bleeding replacement
at puncture sites, vaginal
spotting, heavy menses.
 Intracranial Bleeding in the Abdomal
Bleeding Lungs bleeding
Destruction of
large number of
WBC
Altered Tachycardia
mental status Hypotension Increase
Decreased Pallor abdominal girth
Release of LOC Diaphoresis Pain
subs. Amt of SOB Guarding
Uric Acid in the
circulation

Increase
Uric acid may metabolism
obstruct renal
tubules

Heat intolerance
Weight loss
Dyspnea on
Renal exertion
insufficiency Tachycardia
 Infiltration in the CNS, CT scan
testes, skin, GI tract, MRI
lymph nodes, liver, ultrasound
spleen, and other
PAIN
organs

Bone
Swelling of
Spleenamegaly Hepatomegaly marrow/Joint
lymph nodes
infiltration

Lumps in the
neck, groin,
Enlarged Lymph underarm
areas, or
abdomen Meningeal Kidney node
above the
Infiltration Infiltration biopsy collarbone

Headache Decreased
Altered LOC Renal function
Urine
Cranial impaired Output
nerve
impairment
n/v Increase
BUN and
crea
 COMPLICATIONS
• Leukostasis; in setting of high numbers (greater than 50,000/mm3)
of circulating leukemic cells (blasts), blood vessel walls are
infiltrated and weakened, with high risk of rupture and bleeding,
including intracranial hemorrhage.

• Disseminated intravascular coagulation(DIC).

• Tumor lysis syndrome: rapid destruction of large numbers of

malignant cells leads to alteration in electrolytes (hyperuricemia,
hyperkalemia, hyperphosphatemia, and hypocalcemia).

• May lead to renal failure and other complications.

• Infection, bleeding, and organ damage.

 DIAGNOSTIC EXAMS
• CBC and blood smear – peripheral
WBC count varies widely from 1,000
to 100,000/mm3 and may include
significant numbers of abnormal
immature (blast) cells,

• anemia may be profound-usually

indicates normocytic, normochromic
anemia;

• platelet count may vary from normal

to very low (less than 50,000/mm3)
and coagulopathies may exist.

• Hgb may be less than 10g/100ml.

 • Normal blood as seen
through a microscope.

• The red disks are normal

red cells;

• the largest arrow points

to a mature lymphocyte,

• the smaller arrow points

to a mature myeloid cell,

• and the small

arrowheads indicate
platelets. 
A normal mature lymphocyte (left) and a
lymphoblast (right).
 normal mature myeloid cell (left) and a
myeloblast (right).
 DIAGNOSTIC EXAMS
• Bone marrow aspiration and biopsy – Abnormal WBCs usually make
up 50% or more of the WBCs in the bone marrow. Cells are also
studied for chromosomal abnormalities (cytogenetics) and
immunologic markers to classify type of leukemia further. The
Philadelphia chromosome is the diagnostic marker for CML which
results from translocation of genetic material between
chromosomes 9 and 22.
•
• Lymph node biopsy – to detect the spread.

• Lumbar puncture and examination of cerebrospinal fluid for

leukemic cells (especially ALL). 
• CT scan- determine the presence of leukemic cells outside of the
blood and bone marrow.
 MEDICAL MANAGEMENT
• Chemotherapy
• Radiation Therapy
• Leukapheresis (or exchange transfusion to infants) may be
used when abnormally high numbers of white cells are
present to reduce the risk of leukostasis and tumor burden
before chemotherapy.
• Bone marrow transplant is often used in conjuction with or
following chemotherapy or radiation. It could be allogenic
or autologous.
• Allogenic Stem cell transplant is an alternative to bone
marrow transplant. SCT results in complete and sustained
replacement of the recipient’s blood cell lines with cells
derived from the donor stem cells.
 MEDICAL MANAGEMENT
• Antineoplastic agents
• Supportive treatments during cancer treatment include:
• Antibiotics and immunoglobulin help to prevent or fight infections.
• Corticosteroids
• Transfusions of red blood cells and platelets.
• Epoetin and hematopoietic stimulants help your body make new blood
cells.
• Allopurinol to prevent kidney problems and gout.
• Immune globulin (IG) helps prevent infections. It is sometimes used for
people with chronic lymphocytic leukemia (CLL), because CLL weakens the
immune system.
• Interferon alfa helps your immune system fight disease and may keep
cancer cells from growing. It is often given to people who have CML.
• Antiemetic for vomiting
•  
• Administer blood components as directed. Platelet
transfusions may be necessary when platelet count
<20,000/mm3 or with active bleeding Other blood
products may also be required.

• Keep patient on bed rest during bleeding episodes.

• Teach patient to avoid activities likely to cause

injury(eg, contact sports) and other methods to
prevent bleeding.
•  
 Nursing Diagnosis #1: Risk for infection related to
altered WBC production and immune function
– Promptly report manifestations of infection:.

– Institute infection protection measures:

• Maintain protective isolation as indicated.
• Ensure meticulous hand washing among all people in
contact with the client.
• Assist as needed with appropriate hygiene measures.
• Restrict visitors with colds., flu, or infections.
• Provide oral hygiene after every meal.
• Avoid invasive procedures when possible, including
injections, intravenous catheters, catheterizations, and
rectal and vaginal procedures. When necessary, use strict
aseptic technique for all invasive procedures and monitor
carefully for infection.
 – Monitor vital signs

– Monitor neutrophil levels for relative infection:

Neutrophils are the first line of defense against infection. As
the levels decrease, the risk for infection increases.
 
• Explain infection precautions and restrictions and their
rationale.

• Avoid crowds and avoid raw or undercooked food; use

condoms. This potential for infection remains after discharge.
Avoid exposure to all sources of stagnant water (eg flower
vases, denture cups,) and plants. Stagnant water and soil are
good media for anaerobic bacterial growth.
 Nursing Diagnosis #2: Risk for Injury related to
bleeding secondary to bone marrow failure,
thrombocytopenia
• Watch for signs of minor bleeding, such as petechiae,
ecchymosis, conjunctival hemorrhage, epistaxis, bleeding gums,
bleeding at puncture sites, vaginal spotting, heavy menses.

• Be alert for signs of serious bleeding, such as headache with

change in responsiveness, blurred vision, hemoptysis,
hematemesis, melena, hypotension, tachycardia, dizziness.
Watch out also for complaints of epigastric pain, diminished
bowel sounds, increasing abdominal girth, rigidity or guarding.

• Provide soft toothbrush or toothettes and mild mouthwash for

mouth care. This minimizes damage to mucous membranes.
 NURSING
INTERVENTIONS
• Use only an electric razor for shaving. Keep fingernails and toenails
short and smooth. Lubricate skin with mild lotion. This minimizes
skin excoriation

• Avoid invasive procedures. Biopsy or lumbar puncture should not

be done if platelet count is less than 50, 000.

• Instruct to avoid forcefully blowing or picking the nose, forceful

coughing or sneezing, and straining to have a bowel movement.
These activities can damage mucous membranes, increasing the
risk for bleeding.

• Test all urine, stool, emesis for gross and occult blood.
• Monitor platelet counts daily.
 Nursing Diagnosis #3: Acute pain and discomfort
related to mucositis, leukocyte infiltration of systemic
tissues, fever and infection
• Goal: Ease pain and discomfort
•  
– Assess at least q4h for presence, location, intensity, and
characteristics of pain. Pain is potentially distressing
symptom. Pain may be symptom of infection.

– Administer analgesics as ordered to control pain.

Administer on regular schedule rather than as needed.
Avoid aspirin and NSAIDS in thrombocytopenic patients. If
oral analgesics in optimal doses are not effective or
tolerated, consider IV route.
– Teach and use nonpharmacologic
measures, such as the use of music,
relaxation breathing, progressive muscle
relaxation, distraction and imagery to help
manage pain.

– Maintain environment conducive to rest

– Place in a comfortable position; may

coordinate with analgesics
 Nursing Diagnosis # 4: Activity intolerance related to general
weakness, hypermetabolic state, imbalance between oxygen
and supply and demand, effect of drug therapy
• Goal: Improving Activity tolerance

– Evaluate reports of fatigue. Effects of leukemia, anemia

and chemotherapy may be cumulative, necessitating
assistance.

– Encourage to keep a diary of daily routines and energy

levels, noting activities that increase fatigue. This helps
client prioritize activities and arrange them around fatigue
pattern

– Provide quiet environment and uninterrupted rest

periods. Encourage rest periods before meals.
 – Implement energy-saving techniques; e.g. sitting,
rather than standing, use of shower chair. Assist with
ambulation/other activities as indicated. Maximizes
available energy for self-care tasks

– Recommend small, nutritious, high-protein meals and

snacks throughout the day. Schedule meals around
chemotherapy. Give oral hygiene before meals.
Smaller meals require less energy for digestion.
Increased intake provides fuel for energy

– Provide supplemental oxygen as indicated. This

maximizes oxygen available for cellular uptake,
improving tolerance of activity.
•  
•  
Nursing Diagnosis #5: Imbalanced nutrition, less than
body requirements related to hypermetabolic state,
anorexia, mucositis, pain and nausea 
• Goal: Improving Nutritional Intake
•  
– Weigh regularly and evaluate weight loss over time to
determine degree of malnutrition. A weight loss of
10% or 20% may indicate malnutrition.
– Address causative or contributing factors to
inadequate food intake.
• Provide mouth care before and after meals; use a soft
toothbrush or sponges as necessary.
• Increase liquid intake with meals.
• Ensure the environment is clean and odor free
 • Provide medications for pain and nausea 30 minutes
before meals, as prescribed

• Provide rest periods before meals

• Offer small, frequent meals

• Provide commercial supplements, such as Ensure

• Suggest measures to improve food tolerance, such as

eating dry foods when arising, consuming salty foods if
allowed, and avoiding very sweet, rich, or greasy foods.

– Parenteral nutrition is often required to maintain

adequate nutrition.
•  
 Childhood Leukemia and Proximity to
Nuclear Power Plants
• Increased childhood leukemia rates around Britain’s
Sellafield nuclear power plant(NPP)

• International Journal of Cancer-children under the age of 5

years living within 5 km of an NPP were at more than
double the normal risk of developing leukemia

• Significant risk-distance association

• Thus, currently, ionizing radiation is the onlly established

environmental risk factor for childhood leukemia
 -END-

Thank you…